Policy-making and the reality of health and care

So what is this policy-making reality, what makes it happen, and what does it mean for us standing outside, scratching our heads?

To rewind. This is something I know a little about, having spent a decade and a bit in various ‘policy’ jobs inside and out of government, predominantly in the Department of Health. I’m still trying to work out whether spending 250 hours cajoling the 2012 Health and Social Care Act through Parliament is something I should be proud of, or deeply ashamed.

The concept of what policy is and how could it be better fascinates me (I wrote a rather grandly entitled manifesto back in 2019 on the topic). But the words of my former colleague Tim Gardner still resonate about not adopting cynicism about policy-makers by default.

A lovely aim, but rather hard in practice – as shown by a task I set on Twitter for people’s favourite metaphor as to what health policy-making really is.

So, by metaphor, policy-making was invariably a meal –

Far too often it’s designing fancy recipes without ever putting the pan on the hob and making the dish. Let alone eating it. Which is not how good food is created.

— Charlotte Augst (@CharlotteAugst) November 16, 2021

Or maybe like furniture assembly –

IKEA flat pack. Centre assumes everyone has same materials and instructions, but they don’t. Some have bits missing. Some don’t have an IKEA. And some have had a Chippendale workshop available for 30 years. Chippendale shared as good practice: materials unchanged.

— Mark Redhead (@markredhead) November 17, 2021

Or people talking past each other –

Two people taking completely different languages who realise that they don’t have to talk at all but just take time to look and listen and explore what’s in front of them and then invent their own language fit for their place

— Dr Adrian Hayter (@Dochayter) November 16, 2021

Or some sort of game –

Monopoly? All the players have their own favourite sacred strategies for how to win (Get the utilities! Get the yellows! Integrate care!). You turn a card and suddenly the guy in the big hat changes the rules and send you back to the start…

— Catherine Foot (@csfoot) November 16, 2021

What stands out? First, the level of negativity – nicely summed up by Helen Buckingham: “Finding the responses here a bit depressing… whilst also recognising them. We must be able to do better than this.”

The only metaphor that held any positivity at all was whether we were making slow progress (while doing a marathon on a 400m track).

The metaphors – and others ranged from whack-a-mole to Supermarket Sweep, pin the tail on the donkey to cat-herding – raise a host of exasperated questions: What on earth is going on? Why aren’t you learning? Are you trying to be unhelpful? Do you just not understand healthcare? Why don’t you listen?

The reality of reality

All fair. But really, why is reality the way it is? Three reasons to start off:

1. It’s complicated. The official model of how policy should be made is neat, plausible, and wrong. The far closer model is that shown by system maps (such as for childhood obesity): spaghetti like chains of interlinking, overlapping factors, and where trying to think of linear stage-by-stage process is simply not possible. Push one button over here and another pops up over there.
2. Trade-offs are inevitable. Is cancer more important than dementia? Should nurses get a bigger pay-rise than doctors? Should social care reform protect the asset-poor, or the well-housed rich? Given the scale of national health policy, there’s barely a decision to be made which won’t create winners and losers. Who’s right?
3. It’s political by design. The policy metaphors stress the apparent absence of rationality: why doesn’t policy just do the right thing for the health service? Even if you could work that out (see 1 and 2 above), we too easily forget the NHS is an exceptionally politically driven system – and we want it to be that way. In 1948 power was given on a plate to the Minister for Health. In 2012 any suggestion of reducing the role of the Secretary of State was incredibly controversial. We can try and blame individual politicians, but they’re as equally trapped as anyone else in a system that demands they do something. As Nick Timmins has written about, when Aneurin Bevan wrote about the sound of bedpans reverberating around Westminster, he probably wasn’t meaning it as a good thing – but that’s the system we have.

Policy-makers have a hard job. No one becomes a policy-maker in order to perpetuate “a game of consequences … where you’re writing the next bit of the sentence without any real grasp of the bit that came before” or “Squid game: constructed and planned on paper, and then grimly observed at a distance.”

Most of the policy-makers I know are great people, often feeling a sense of guilt about policy’s limitations. In short, we have a system that makes good policy-making exceptionally difficult.

But let’s not settle for the ridiculousness we see too much of. The reality of health and care is one person – working with others, using their expertise, giving care and kindness – helping another person.

That’s a jaw-droppingly beautiful pursuit in life. And that’s the bar the reality of health policy-making should aspire to as well.